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z <br />` SAN JOAQUiN Environmental Health Department <br />f.; COUNTY <br />GrPotness prows here. <br />SITE MITIOAT OV VVELL 8 B O R IG PERMIT APPLICAT OVA <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All Inspections <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards, <br />Job Address 23701 South Santa Fe Road <br />Cross Street Henry Road <br />Property Owner* <br />Brilliant Nest Inc <br />Address 23565 S. Santa Fe <br />C-57 Contractor V&W Drilling <br />Address 1133 Blackhurst Drive <br />Consultant/Sub-Contractor Condor Earth <br />Address 188 Frank West Circle, Suite I <br />City/State/Zip Riverbank/CA/95367 <br />qpN 249-060-120 <br />Phone <br />Phone <br />City/State/Zip Riverbank/CA/95320 <br />License# C57 #720904 Phone <br />City/State/Zip Galt/CA/95632 <br />License# PG #9945 Phone <br />(209) 550-1154 <br />(20)513-7634 <br />/State/Zi <br />p Stockton/CA/95206 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLIBORING NUMBER <br />❑ MONITORING ❑ <br />❑ EXTRACTION (VaporlWater) ❑ <br />❑ INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />SOIL VAPOR PROBE ❑ <br />❑ SOIL BORING ❑ <br />❑ INJECTION (Air soaroe. ozone) ❑ <br />❑ OTHER ❑ <br />WELU SOIL BORING IDs <br />HOLLOW STEM 80RING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />HAMMER/DRIVEN DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (cttEcl<ALLTIiATAPPLY) <br /># WELLS TO BE DESTROYED 1 ❑OVER -BORE DIAMETER of inches to depth of <br />WELL 10 MW -8 ❑ PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS Neat Cement ❑x EXPLOSIVES From 26 to 40 feet below surface <br />TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑x PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet belo <br />COMMENTS: Explosives will be placed below the sanitary <br />Signed -�-� <br />Print Name Luke Castle <br />seal to depth. Detenation by Tylor McMillian Cert of Eligibility Bureau of Firearms #13854 <br />/ that I am authorized to complete this application and that 4he work will be done in accordance with <br />Joaquin Count Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company <br />Condor Earth Geologist <br />Date <br />feet <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Farility/Sita Information <br />FA Name <br />Address <br />Z <br />3 <br />FA# <br />O O <br />PR# <br />O <br />FA PE <br />/J a 60 <br />WP Reviewed By <br />Work Plan Datecwow�w <br />�2 <br />❑ C-57 57 Authorization for Other to Sign Permit <br />❑ Worker's Comp ❑ Worker's Comp Waiver []Encroachment Permit <br />cress Agreement Lead <br />Agency Approval % MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE <br />PE <br />SC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />WELL PERMIT# <br />INVOICE# <br />Permit <br />3 J <br />152 x <br />2 <br />C L <br />D %Q rZ <br />W too 20 <br />59 <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3 20 � F 209 464-0138 1 vvww.sjcehd.com <br />EHD 29-0108-01-17 +t 1503 <br />5� 6 3 Site Mitigation Well Permit Application <br />